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Wolff Parkinson White Syndrome in Pregnant Woman with Frequent Syncope Fetal Heart Sounds

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Wolff Parkinson White Syndrome in Pregnant Woman with Frequent Syncope Fetal Heart Sounds Powered By Docstoc
					Thai Journal of Obstetrics and Gynaecology
September 2000, Vol. 12, pp. 247-249


CASE REPORT


Wolff-Parkinson-White Syndrome in Pregnant
Woman with Frequent Syncope

Sakol Manusook MD.
Faculty of medicine, Thammasat University, Pratumthani, Thailand



                                             ABSTRACT

       Syncope is a symptom that frequently occurs in pregnant woman. Most of the
causes are benign, but some cardiac abnormality should be looked for in the woman
with multiple attacks. We present a case of pregnant woman with Wolff- Parkinson-
White syndrome that diagnosis was made during pregnancy.

Key words:        Wolff-Parkinson-White syndrome, pregnancy, syncope


        Pregnancy is a condition that can precipitate arrhythmia and tachycardia.
Although most of pregnant women have increased heart rate during her gestation without
any symptom, some woman may develop fainting or arrhythmia. Wolff-Parkinson-White
syndrome is one form of ventricular preexcitation that can produce symptoms of syncope,
palpitation, arrhythmia or sudden death1. Most of pregnant women with syncope or
palpitation get an advice of normal physiologic change but some woman may have real
cardiac abnormality. This syndrome may be diagnosed firstly during pregnancy from
closed observation while she attends antenatal care clinic or from investigation of
arrhythmia that she has. We present a case of Wolff-Parkinson- White syndrome in
pregnant woman who visited antenatal care clinic and delivered at Thammasat university
hospital.
                  A                                                      B

                 Fig. 1. ECG at 14 weeks of gestation (A) and during labor (B).

Case report
         A 34-year-old gravida3 para1 which one term pregnancy that delivered by forceps
extraction with unknown indication from other hospital and one ended by inducing abortion
at 8 weeks of gestation visited Thammasat hospital firstly at 12 weeks of gestation. She
followed up regularly and complained of frequent syncope even during rest or exertion.
Her uterine size was compatible with gestation age and no other abnormality was found.
During pregnancy, her blood pressure was between 100-110 mmHg systolic and 60-70
mmHg diastolic and pulse rate was between 80-90beats/ min. hysical examination
revealed no neck vein engorgement, normal heart sound, no murmur and no cardiac
enlargement. Electrocar-diography (ECG) was performed at 14 weeks of gestation and
illustrated as figure 1. Chest film and echocardiography were performed by cardiologist
but no sign of any cardiac abnormality. No medication except iron and vitamin
supplements were prescribed. She had spontaneous labor at 39 weeks of gestation and
she was monitored with ECG and fetal monitoring during first and second stage of labor
but no arrhythmia or fetal distress found. She was delivered by forceps extraction for
shortening of second stage of labor. The infant was a healthy female weighing 3000 g with
Apgar score of 8 and 9 at 1 and 5 minutes, respectively. After delivery, she was monitored
with Holter monitoring for 24 hours but no sign of arrhythmia or tachycardia found. She
and her baby were discharged 3 days later and she was advised for radiofrequency
ablation.

Discussion
         The Wolff-Parkinson- White ( WPW )syndrome estimated to occur in
approximately 0.1 to 3.0 per 1000 of the general populations, is the form of ventricular
preexcitation involving an accessory conduction pathway.2 It occurs when any part of the
ventricular myometrium is activated by an impulse originating in the atrium earlier than
would be expected. The anatomic substrates for the preexcitation syndrome include
several types of accessory A-V connections. The classic electrocardiographic features for
diagnosis of WPW syndrome are 1) a PR interval less than 0.12 seconds 2) a slurring of
the initial segment of QRS complex, known as delta wave 3) a QRS complex widening
with a total duration greater than 0.12 seconds.1,3 However, these criteria are not always
present, and the absence of one or more does not rule out the diagnosis of WPW
syndrome. ECG pattern in this patient showed PR interval of 0.16 seconds, QRS complex
duration of 0.16 seconds and delta wave as illustrated in V5 and V6 lead in figure 1. The
majority of patients with this syndrome remain asymptomatic throughout their lives. When
symptoms do occur they are usually secondary to tachyarrhythmia such as paroxysmal
supraventricular tachycardia, atrial fibrillation, atrial flutter and ventricular fibrillation that
may lead to symptoms of palpitation, syncope or a rare incidence of sudden death. Holer
monitoring was performed after delivery in this patient but can not detect any cardiac
arrhythmia. It may be from short term monitoring and the patient did not have symptoms
during monitoring.
        The WPW syndrome has also been associated with various cardiac abnormalities
such as Ebstein’s anomaly, mitral valve prolapse, cardiomyopathy and congenital cardiac
anomaly.2,4 But in most patients, however, no heart disease is present as in this patient.
Relatives of patient with this preexcitation syndrome, particularly from those with multiple
pathway have an increased incidence of preexcitation, suggesting a hereditary mode of
acquisition. The incidence of WPW syndrome during pregnancy is unknown, but
pregnancy is associated with an increased frequency of arrhythmia in this syndrome.5,6,7,8
Increased adrenergic sensitivity by estrogen, increased plasma volume, stress and
anxiety during pregnancy may be predisposing factors.7
        Treatment of WPW syndrome in pregnancy is generally similar to that in non
pregnant state. No diagnostic or therapeutic intervention is recommended for asymptom-
atic patient. If atrial fibrillation occurs, intravenous procanamide is the treatment of choice
for hemodynamically stable patient. Direct current synchronized cardioversion is
necessary for hemodynamically unstable patient.2,3,9 We did not gave any medication to
this patient except for ECG monitoring because of no cardiac arrrhythmia was found
during pregnancy.
        Afridi and co-worker10 presented successful treatment of narrow complex
tachyarrhythmia before and during delivery in woman with WPW syndrome with
intravenous adenosine. Arrhythmia could be converted to normal sinus rhythm and fetal
heart rate became to normal rate. But he also suggested of avoiding this drug in wide
complex QRS and atrial fibrillation because it could induce ventricular tachycardia.
        Leffler and co-worker11 reported a case in which adenosine was used to treat
supraventricular tachycardia in pregnant woman with WPW syndrome without adverse
effect on mother and fetal heart rate. When the patient is asymptomatic or if the
tachyarrhythmia is rare and tolerate, no long term antiarrhythmic therapy is indicated. For
the patient with frequent and symptomatic tachycardia, quinidine or procanamide plus
beta blocker in combination are treatment of choice. The use of flecainidine, propafenone
and amiodarone are in limit data for pregnant woman.3
        Radiofrequency catheter ablation of the accessory pathway is advisable for this
patient because in a symptomatic arrhythmia which are not fully controlled by drugs, in
patients who are drug intolerant, or in those who do not wish to take drug are the
indication for such a treatment. It has high success rate, low frequency of complication
and potential effectiveness.2

       In conclusion, serious cardiac disease may appear or worsen at the time the
women get pregnancy. Evaluation of the maternal heart should be complete in pregnant
woman with some complaints such as syncope, palpitation or tachycardia that may be
overlooked as physiologic change during pregnancy.
References
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